Competing renewal of, Improving Ventilator Management And Preventing Injury To Patients With Acute Lung Injury and Acute Respiratory Distress Syndrome, we propose building on our work developing a succesful intervention to implement lung protective ventilation in patients with acute lung injury at 10 local hospitals in King County Washington by extending its geographic, clinical, and scientific scope. Acute respiratory failure is a heterogeneous set of disorders requiring ventilatory support including acute lung injury, pneumonia, and exacerbations of chronic lung disease with mortality rates that range from 30% to over 60%. Conservative estimates suggest that acute respiratory failure accounts for 100,000 deaths and over $2.5 billion in medical spending each year in the United States. Effective interventions to reduce this mortality and morbidity are known but are not routinely implemented. These include (1) a lung protective ventilation protocol that reduces mortality in acute lung injury, (2) a respiratory therapist protocol incorporating a daily spontaneous breathing trial that reduces duration of mechanical ventilation, (3) a nursing protocol for sedation that incorporates a daily interruption of sedating medication that reduces duration of mechanical ventilation, (4) semirecumbent positioning that reduces the incidence of ventilator associated pneumonia, (5) noninvasive ventilation for COPD exacerbation that reduces mortality compared to endotracheal intubation. We will partner with Cerner Corporation, a leading provider of healthcare informatics solutions, to accomplish 3 specific aims: (1) To identify barriers and facilitators to implementing guideline based care of mechanically ventilated patients with acute respiratory failure, (2) To develop and pilot a web-based, interactive, multi- media educational and feedback intervention to implement guideline based care of mechanically ventilated patients with acute respiratory failure, and (3) To test the effectiveness of a web-based, interactive, multi- media educational and feedback intervention to implement guideline based care of mechanically ventilated patients with acute respiratory failure in a national network of 40 community hospitals.